A perfect storm

The recent deaths of three psychiatry registrars and a trainee in Victoria and the continuing debate about mandatory reporting regulations accentuate a growing concern about the mental health of medical students, doctors-in-training and practising health care professionals

A storm has been brewing in the medical profession.

It has been a slow developer, a dark cloud that has rumbled quietly but has gone largely unacknowledged for decades.

That began to change in October 2013 with the release of beyondblue’s National Mental Health Survey of Doctors and Medical Students, which laid bare some startling and worrying statistics.1

It came to a head in February of this year when news of the sudden deaths of three psychiatry registrars and one trainee came to light.

“I’m really glad to see this conversation happening”, says Dr Kimberley Ivory, senior lecturer in population health, and sub-dean of student support at the Sydney Medical School.

“It’s a perfect storm that’s been a long time coming.”

beyondblue found that doctors reported substantially higher rates of psychological distress and attempted suicide compared with both the Australian population and other Australian professionals (3.4%, 2.6% and 0.7%, respectively), says the executive summary of the report.

The levels of very high psychological distress in doctors aged 30 years and younger was significantly higher than individuals aged 30 years and younger in the Australian population and other professionals (5.9%, 2.5% and 0.5%, respectively).

About 21% of doctors reported having ever been diagnosed with, or treated for, depression and 6% had a current diagnosis. About 9% of doctors reported having ever been diagnosed with or treated for an anxiety disorder. About a quarter of doctors reported having thoughts of suicide prior to the past 12 months, and 10.4% reported having thoughts of suicide in the previous 12 months.

Doctors in distress

Young doctors and female doctors appeared to have higher levels of general and specific mental health problems and reported greater work stress.

“Young doctors appeared to be particularly vulnerable to poor mental health and high levels of stress. Compared to older doctors (51–60 years), younger doctors reported higher rates of burnout … across the three domains of emotional exhaustion (47.5% vs. 29.1%), low professional efficacy (17.6% vs. 12.8%) and high cynicism (45.8% vs. 33.8%)”, the report found.

“Approximately 40% of doctors felt that medical professionals with a history of mental health disorders were perceived as less competent than their peers, and 48% felt that these doctors were less likely to be appointed compared to doctors without a history of mental health problems.

“Approximately 59% of doctors felt that being a patient causes embarrassment for a doctor.”

Female doctors were more likely than male doctors to view doctors with a mental health history to be as reliable as the average doctor (69% and 55%, respectively).

Forty per cent of students felt that doctors believe that a doctor with a mental health disorder is less competent, and 41.5% felt that doctors with a history of anxiety or depression are less likely to be appointed than other doctors.

The deaths of the three psychiatry registrars (working at St Vincent’s, Austin and Frankston hospitals, respectively, in Melbourne) and one intern who was a week into an internship at Geelong Hospital, were first reported by the ABC on 3 February of this year.2

College response

Dr Murray Patton, president of the Royal Australian and New Zealand College of Psychiatrists, said the college had “recently conducted a survey of the welfare of all members including trainees and established a working group comprised of Fellows and trainees to develop initiatives to support member welfare”.3

In an interview with the MJA, Dr Patton says that in the wake of the registrar deaths there had been some “very useful correspondence from a number of trainees from the Victorian group”.

“I don’t really think it’s as simple as just the pressures of training”, he says.

“Every specialty has its pressures. There are stresses in the working climate and in reaching training milestones. That’s not [unique] to psychiatry.

“Doctors like to be seen as competent and coping. But there are simple messages that can be conveyed. Ask for support. Ask your colleagues if they are okay. Offer support.”

The deaths provoked Dr Ivory to pen a heartfelt piece for crikey.com.au’s health blog, Croakey, titled A call for medicine to stop devouring its young.4

Dr Ivory wrote that simply asking why the young doctors in training didn’t seek help isn’t enough and smacks of “victim-shaming”.

“A recent meta-analysis of 51 studies on harassment and discrimination in medical training showed that 59.4% of medical trainees had experienced at least one form of harassment or discrimination during their training”, Dr Ivory wrote.5

“ ‘Teaching by humiliation’ was experienced by 74% of students and witnessed by 84%.

“Often, the perpetrator is also their supervisor or superior. When that is the case, a culture of fear of negative consequences and under-reporting develops. Discrimination in advancement selection processes can be subtle and hard to prove but the fear of it is strong in a competitive profession.

“Many students believe that tolerating such behaviours is a necessary part of professional development rather like the process of hazing or bastardisation favoured in highly masculinised environments like private schools, frat houses and the military”, Dr Ivory wrote.

In an interview with the MJA, Dr Ivory says that her article has received a “massive” response both at home and globally.

Picking on each other

Consultations with students she supervises and mentors revealed to Dr Ivory the kinds of stresses put on students by their superiors and, perhaps most worryingly, their fellow students.

“One student who had failed a subject was really worried about repeating, terrified because of the stigma of repeating”, she says. Facebook abuse, including comments about never going to a doctor who had failed an exam, were common.

“There is no doctor who ever graduated who hasn’t failed something.

“Students pick on each other.”

Medical education functions by teaching through modelling, Dr Ivory says. Students see a behaviour modelled by a successful older doctor, and copy that behaviour — adopting and perpetuating bullying, teaching by humiliation and, in extreme cases, sexual harassment.

“Medical culture is at the core of this issue. That culture is entrenched by modelling”, she tells the MJA.

“There are doctors who shame doctors. And there is a stigma within the wider community as well, that doctors should be infallible.

“[That stigma is] a definite barrier to stopping doctors [with mental health issues] from accessing support. And that’s particularly true of young doctors in their training years because of the fear that it will somehow be detrimental to their progression.

“It’s also true of doctors in smaller communities where they may be known to all of the local psychological and counselling services, the local pharmacy.”

There is no simple solution, Dr Ivory believes.

“It is very much about context. I think it depends very much on the individual and the situation in which they find themselves — personalities, the colleagues we’re surrounded by, the work environment we’re in.

“It’s a very complex industry. It’s not enough to talk about ‘this is what should happen’, because there have to be responses from all of those areas of medicine.

“There will be a generational change because I see younger doctors are much more aware of work–life balance and the issues around mental health.

“But we can’t wait for that generational change to happen because the culture is so entrenched and replicated by modelling.”

Putting it in context

Dr Ivory tells the MJA that the Sydney School of Public Health is currently preparing a pilot program of workshops designed to start tackling the “institutional culture that seems to be the root cause of this persistent, pervasive and destructive problem”.

The program aims to teach medical students and trainees how to model more positive behaviours using acting techniques.

“Actors take on a role, just as doctors take on a role, but they have the skills to interpret that role in the context in which they find themselves, and then to modify it according to the dynamic of what’s happening around them”, Dr Ivory says.

“There is no script, things happen. If you’ve got skills that allow you to interpret what’s happening and then respond to it in a way that is central to your core beliefs, we believe we can impact positively on the culture.”

Mandatory reporting

Entangled in the issue of mental health in the medical profession is a reheating of the debate surrounding mandatory reporting of doctors.

An ABC Background Briefing recently quoted Western Australia’s health minister and deputy premier, Kim Hames, saying his state has unintentionally become a “safe haven” for unwell doctors after it decided 4 years ago to have different reporting laws to the rest of the country.6

The mandatory reporting laws were introduced in 2010 following the Dr Jayant Patel case in Queensland and the Dr Graham Reeves case in New South Wales.

Doctors treating other doctors are required to report their patient to the Medical Board of Australia (MBA) and the Australian Health Practitioner Regulation Agency (AHPRA) for inappropriate conduct, including intoxication, sexual misconduct and departures from accepted professional standards.7

They also require the reporting of the doctor if the reporting practitioner “formed a ‘reasonable belief’ that another practitioner placed the public at risk of substantial harm in the practitioner’s practice of the profession because the practitioner has an impairment”, according to AHPRA’s national communications advisor, Nicole Newton.

WA doctors are not required to report when “their reasonable belief about misconduct or impairment is formed in the course of providing health services to a health practitioner or student”.

Critics of the laws say angst about mandatory reporting laws is being caused by confusion about the wording of the impairment clause.

“The threshold for the need for reporting is high”, Dr Flynn tells the MJA. “An unwell practitioner whose health is being well managed does not need to be reported to the Board. There needs to be a good reason to believe there is a risk of harm to the public.

“There is also a misunderstanding about what actually happens when there is a notification.”

The process was not a direct route from notification to sanction, she says.

“After notification there is an assessment of the risk and then in very rare instances it has to be taken further. If there is no evidence of risk, the Board takes no action.”

According to the MBA’s report — Medical regulation at work in Australia, 2013/14 — in 142 of the 231 mandatory notifications (61%) closed in 2013–14, the Board determined that no further regulatory action was required to keep the public safe.8